Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs)

Transcription

1 Express Scripts Medicare (PDP) 2019 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 19058, v4 This formulary was updated on 08/24/2018. For more recent information or to price a medication, you can visit us on the Web at express-scripts.com. Or you can contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Medco Containment Life Insurance Company or Medco Containment Insurance Company of New York (for employer plans domiciled in New York). When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of August 24, For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, premium and/or copayments/coinsurance may change on January 1, The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. CRP1805_0216 F0PP4Z9A

2 What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of covered Medicare Part D drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at express-scripts.com or contact Customer Service. Express Scripts Medicare will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug covered by your plan in 2019, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 2019 coverage year, except when a new, less expensive generic drug becomes available or new information about the safety or effectiveness of a drug is released or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our plan s formulary, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. New generic drugs. We may immediately remove a brand-name drug on our formulary if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our formulary, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the formulary? s removed from the market. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand-name drug currently on the formulary or add new restrictions to the brand-name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy i

3 restrictions on a drug or move a drug to a higher cost-sharing tier, if applicable, we must notify affected members of the change at least 30 days before the change becomes effective or at the time the member requests a refill of the drug, at which time the member will receive a one-month supply of the drug. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 66. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. ii

4 You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 1. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at express-scripts.com or contact Customer Service. You can ask us to make an exception to these restrictions or limits. See the section How do I request an exception to the formulary? below for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that your drug is not covered, you have two options: You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request a formulary exception so that the plan will cover the drug you are taking. How do I request an exception to the formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level. If your drug is contained in our Non-Preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our Preferred Brand tier instead. If approved, this would lower the amount you must pay for your drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in our Specialty tier. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting an exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. iii

5 Generally, your request for an exception will only be approved if the alternative drugs that are included in the plan formulary, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document. Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year. For each of your drugs that is not on our formulary, or if your ability to get drugs is limited, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for a one-month supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum of a one-month supply of medication. After your first refill of a one-month supply, we will not pay for these drugs, even if you have been a plan member less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if your ability to get your drug is limited but you are past the first 90 days of membership in our plan, we will cover a minimum of a 31-day emergency transition supply of that drug while you pursue an exception. Other times when we will cover at least a temporary 30-day transition supply (or less, if you have a prescription written for fewer include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options. iv

6 Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 66. The column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a different cost-sharing amount. The s chart below explains what types of drugs are included in each tier and shows how costs may change with each tier. Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. v

7 s Includes Helpful tips 1: Generic s 2: Preferred Brand s 3: Non- Preferred s 4: Specialty s This tier includes many commonly prescribed generic drugs and may include other low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. This tier includes very high cost brand-name and generic drugs. Use 1 drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than non-preferred drugs. Many non-preferred drugs have lower-cost alternatives in s 1 and 2. Ask your doctor if switching to a lower-cost generic or preferred brand-name drug may be right for you. To learn more about medications in this tier, you may contact a pharmacist using the information provided on the front and back covers of this formulary. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or visit vi

8 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan s specific coverage, contact Customer Service using the information provided on the front and back covers of this formulary or visit us on the Web at express-scripts.com. List of abbreviations LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary. MO: Mail-Order. This prescription drug is available through our home delivery service, as well as through our retail network pharmacies. Consider using home delivery for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover this drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. vii

9 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 PA; MO AMBISOME 4 PA; MO amphotericin b 1 PA; MO caspofungin 4 PA clotrimazole mucous membrane CRESEMBA ORAL fluconazole fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize 1 itraconazole ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral ANTIVIRALS abacavir abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution 1 PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 200 mg atazanavir oral capsule 300 mg 4 ATRIPLA 1

10 BARACLUDE ORAL SOLUTION BIKTARVY COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg EDURANT efavirenz oral capsule 200 mg efavirenz oral capsule 50 mg efavirenz oral tablet EMTRIVA entecavir EPCLUSA (28 per 28 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN GENVOYA HARVONI (28 per 28 INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION lopinavir-ritonavir moderiba 2

11 moderiba oral tablets,dose pack 200 mg (28)- 400 mg (28), mg (28)-mg (28) moderiba dose pack oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28) nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION 2 ODEFSEY oseltamivir PREVYMIS ORAL ; QL (30 per 30 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg 1 rimantadine ritonavir SELZENTRY stavudine oral capsule 3

12 STRIBILD SYMFI SYMFI LO tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ TRUVADA valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg ; QL (120 per 30 ; QL (60 per 30 valganciclovir VEMLIDY VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 125 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG 3 MO 3 MO ZERIT ORAL RECON SOLN 3 MO zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 1 cefadroxil oral tablet cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram cefdinir cefepime cefixime 1 4

13 cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefotetan injection 1 cefoxitin intravenous recon soln 1 gram, 2 gram cefoxitin intravenous recon soln 10 gram 1 cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin 1 SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 3 MO 3 3 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 5

14 erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil aztreonam injection recon soln 1 gram BENZNIDAZOLE 2 BETHKIS (224 per 28 CAYSTON ; LA; QL (84 per 28 chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) 1 dapsone oral daptomycin intravenous recon soln 500 mg DARAPRIM 4 PA; MO EMVERM ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/100 ml gentamicin injection solution 40 mg/ml 1 hydroxychloroquine imipenem-cilastatin 6

15 INVANZ INJECTION 3 MO isoniazid oral ivermectin linezolid linezolid in dextrose 5% mefloquine meropenem metronidazole in nacl (iso-os) 4 metronidazole oral NEBUPENT 2 PA; MO; QL (1 per 28 neomycin paromomycin PASER PENTAM 3 MO polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA STREPTOMYCIN tigecycline 4 tinidazole TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl tobramycin sulfate injection solution 4 QL (224 per 28 ; QL (224 per 28 (280 per 28 TRECATOR vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet ; QL (9 per 30 ; QL (60 per 30 7

16 amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML 1 BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml 1 oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram oxacillin injection recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g sodium penicillin v potassium 8

17 piperacillintazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin 1 ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous levofloxacin oral moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg 1 SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazoletrimethoprim oral TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 150 mg, 20 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet morgidox oral capsule 50 mg tetracycline VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS methenamine hippurate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim 9

18 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium oral MESNEX ORAL XGEVA 4 PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS AFINITOR (30 per 30 AFINITOR DISPERZ 4 PA; MO ALECENSA (240 per 30 ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (60 per 30 (30 per 30 anastrozole azathioprine 1 PA; MO bexarotene 4 PA; MO bicalutamide BOSULIF ORAL TABLET 100 MG (90 per 30 BOSULIF ORAL TABLET 400 MG, 500 MG (30 per 30 CABOMETYX 4 PA; MO; LA CALQUENCE 4 PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (30 per 30 COMETRIQ 4 PA; MO COTELLIC 4 PA; MO; LA; QL (63 per 28 cyclophosphamide oral capsule cyclosporine modified cyclosporine oral capsule 1 PA; MO 1 PA; MO 1 PA; MO DROXIA EMCYT ERIVEDGE (30 per 30 ERLEADA 4 PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG (12 per 21 10

19 FARYDAK ORAL CAPSULE 15 MG, 20 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG (6 per 21 4 PA; MO 2 PA; MO flutamide gengraf oral capsule 100 mg, 25 mg gengraf oral solution 1 PA; MO 1 PA; MO GILOTRIF (30 per 30 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN hydroxyurea IBRANCE (21 per 28 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG (60 per 30 (30 per 30 IDHIFA 4 PA; MO; LA; QL (30 per 30 imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG (180 per 30 (60 per 30 (120 per 30 (30 per 30 (30 per 30 (180 per 30 (120 per 30 IRESSA (30 per 30 JAKAFI (60 per 30 KISQALI 4 PA; MO KISQALI FEMARA CO-PACK 4 PA; MO LENVIMA 4 PA; MO letrozole LEUKERAN 11

20 leuprolide subcutaneous kit LONSURF 4 PA; MO LUPRON DEPOT 4 PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET 4 PA; MO 4 PA; MO 4 PA; MO (480 per 30 (120 per 30 LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml 1 PA; MO megestrol oral tablet 1 PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG (90 per 30 (30 per 30 mercaptopurine methotrexate sodium 1 PA; MO methotrexate sodium (pf) injection solution 1 PA; MO mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium 1 PA; MO 4 PA; MO 1 PA; MO 1 PA; MO NERLYNX 4 PA; MO; LA NEXAVAR 4 PA; MO; LA; QL (120 per 30 nilutamide NINLARO ORAL CAPSULE 2.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml (6 per 28 (4 per 28 (3 per 28 ODOMZO 4 PA; MO; LA; QL (30 per 30 POMALYST 4 PA; MO; LA PURIXAN 12

21 RAPAMUNE ORAL SOLUTION 4 PA; MO REVLIMID 4 PA; MO; LA; QL (28 per 28 RUBRACA 4 PA; MO; LA; QL (120 per 30 RYDAPT 4 PA; MO SANDIMMUNE ORAL SOLUTION 2 PA; MO SIGNIFOR sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet 2 mg 1 PA; MO 4 PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 20 MG SPRYCEL ORAL TABLET 70 MG (30 per 30 (90 per 30 (60 per 30 STIVARGA (84 per 28 SUTENT (30 per 30 SYNRIBO 4 PA; MO TABLOID tacrolimus oral 1 PA; MO TAFINLAR (120 per 30 TAGRISSO 4 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG, 200 MG TASIGNA ORAL CAPSULE 50 MG (30 per 30 (60 per 30 4 PA; MO (112 per 28 (120 per 30 THALOMID 4 PA; MO TRELSTAR 4 PA; MO tretinoin (chemotherapy) TYKERB 4 PA; MO; LA; QL (180 per 30 VENCLEXTA ORAL TABLET 10 MG, 50 MG 2 PA; MO; LA 13

22 VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK 4 PA; MO; LA 4 PA; MO; LA; QL (42 per 180 VERZENIO 4 PA; MO; LA; QL (60 per 30 VOTRIENT (120 per 30 XALKORI (60 per 30 XATMEP 4 PA; MO XERMELO 4 PA; MO; LA; QL (90 per 30 XTANDI (120 per 30 YONSA 4 PA; QL (120 per 30 ZEJULA 4 PA; MO; LA; QL (90 per 30 ZELBORAF (240 per 30 ZOLINZA ZORTRESS 4 PA; MO ZYDELIG (60 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG (120 per 30 (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG 3 MO BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable 3 14

23 CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg 1 PA; MO; QL (90 per 30 1 PA; MO; QL (300 per 30 1 PA; MO; QL (90 per 30 1 PA; MO; QL (300 per 30 DIASTAT 3 MO DIASTAT ACUDIAL 3 MO DILANTIN 30 MG divalproex epitol ethosuximide felbamate oral suspension felbamate oral tablet FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg 1 PA; MO; QL (1080 per 30 1 PA; MO; QL (360 per 30 gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GRALISE 30-DAY STARTER PACK GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 600 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack 1 PA; MO; QL (270 per 30 1 PA; MO; QL (2160 per 30 1 PA; MO; QL (180 per 30 1 PA; MO; QL (120 per 30 2 PA; MO; QL (78 per PA; MO; QL (30 per 30 2 PA; MO; QL (90 per 30 15

24 levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG 2 PA; MO; QL (90 per 30 2 PA; MO; QL (60 per 30 2 PA; MO; QL (900 per 30 (480 per 30 (60 per 30 oxcarbazepine PEGANONE phenobarbital 1 PA; MO phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended primidone roweepra roweepra xr 1 SABRIL ORAL TABLET ; LA SPRITAM 3 MO tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 1 PA; MO 1 PA; MO valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml vigabatrin ; LA VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide 1 PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine oral 1 PA; MO bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO pramipexole 16

25 rasagiline ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine nasal ; QL (8 per 28 eletriptan ; QL (18 per 28 ergotamine-caffeine migergot naratriptan ; QL (18 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector ; QL (18 per 28 ; QL (36 per 28 ; QL (18 per 28 ; QL (8 per 28 ; QL (8 per 28 sumatriptan succinate subcutaneous solution sumatriptannaproxen ; QL (8 per 28 ; QL (18 per 28 zolmitriptan ; QL (18 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 4 PA; MO; LA AUBAGIO 4 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML (12 per 28 donepezil galantamine GILENYA ORAL CAPSULE 0.5 MG glatiramer subcutaneous syringe 20 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 20 mg/ml glatopa subcutaneous syringe 40 mg/ml memantine oral capsule,sprinkle,er 24hr 4 PA; MO (30 per 30 (12 per 28 (30 per 30 (12 per 28 1 PA; MO 17

26 memantine oral solution memantine oral tablet 1 PA; MO 1 PA; MO NAMZARIC 2 PA; MO NUEDEXTA 2 PA; MO rivastigmine rivastigmine tartrate TECFIDERA 4 PA; MO; LA tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg (240 per 30 (120 per 30 MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 20 mg cyclobenzaprine oral tablet 1 PA; MO dantrolene MESTINON ORAL SYRUP pyridostigmine bromide tizanidine NARCOTIC ANALGESICS acetaminophencodeine oral solution mg/5 ml ; QL (4500 per 30 acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl sublingual duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, mg, mg ; QL (360 per 30 ; QL (180 per 30 ; QL (4000 per 30 1 QL (2000 per 30 ; QL (360 per 30 fentanyl citrate (120 per 30 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 72 hour 87.5 mcg/hour hydrocodoneacetaminophen oral solution mg/15 ml 1 PA; MO; QL (10 per 30 (10 per 30 ; QL (5550 per 30 18

27 hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg hydromorphone oral tablet extended release 24 hr 16 mg, 32 mg ; QL (390 per 30 ; QL (360 per 30 ; QL (50 per 30 ; QL (240 per 30 1 QL (1200 per 30 ; QL (2400 per 30 ; QL (180 per 30 1 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone ; QL (28 per 30 levorphanol tartrate ; QL (120 per 30 lorcet (hydrocodone) ; QL (360 per 30 lorcet hd ; QL (360 per 30 lorcet plus oral tablet mg methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine injection syringe 10 mg/ml morphine injection syringe 2 mg/ml morphine injection syringe 4 mg/ml morphine injection syringe 5 mg/ml morphine injection syringe 8 mg/ml morphine oral capsule, er multiphase 24 hr ; QL (360 per 30 1 PA; MO; QL (600 per 30 1 PA; MO; QL (1200 per 30 1 PA; MO; QL (120 per 30 1 PA; MO; QL (240 per 30 ; QL (900 per 30 ; QL (200 per 30 ; QL (1000 per 30 ; QL (500 per 30 1 QL (400 per 30 1 QL (250 per 30 1 PA; MO; QL (60 per 30 19

28 morphine oral capsule,extend.relea se pellets morphine oral solution 1 PA; MO; QL (90 per 30 ; QL (900 per 30 morphine oral tablet ; QL (180 per 30 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 200 mg, 30 mg, 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg, mg, mg, mg 1 PA; MO; QL (60 per 30 1 PA; MO; QL (120 per 30 ; QL (360 per 30 ; QL (180 per 30 ; QL (1200 per 30 ; QL (180 per 30 ; QL (360 per 30 ; QL (360 per 30 oxycodone-aspirin ; QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg 2 PA; MO; QL (90 per 30 (60 per 30 ; QL (360 per 30 ; QL (180 per 30 vicodin ; QL (390 per 30 vicodin es ; QL (390 per 30 vicodin hp ; QL (390 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate nasal ; QL (360 per 30 ; QL (90 per 30 ; QL (10 per 28 celecoxib diclofenac potassium diclofenac sodium oral 20

29 diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol ; QL (300 per 28 ; QL (1000 per 28 diflunisal etodolac fenoprofen oral tablet FLECTOR 3 PA; MO; QL (60 per 30 flurbiprofen ibu oral tablet 600 mg, 800 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 75 mg ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate mefenamic acid meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg ; QL (30 per 30 nabumetone naloxone naltrexone naproxen naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam profeno 1 SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG ; QL (2 per 28 ; QL (60 per 30 ; QL (360 per 30 ; QL (90 per 30 sulindac tolmetin oral capsule tolmetin oral tablet 600 mg tramadol oral tablet ; QL (240 per 30 tramadolacetaminophen ; QL (240 per 30 PSYCHOTHERAPEUTIC DRUGS 21

30 ABILIFY MAINTENA amitriptyline 1 PA; MO amoxapine 1 PA; MO aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating ; QL (30 per 30 ; QL (60 per 30 ARISTADA armodafinil 1 PA; MO atomoxetine bupropion hcl oral tablet bupropion hcl oral tablet extended release 12 hr bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (60 per 30 ; QL (90 per 30 ; QL (30 per 30 buspirone chlorpromazine oral citalopram oral solution citalopram oral tablet ; QL (30 per 30 clomipramine 1 PA; MO clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg 1 PA; MO; QL (180 per 30 1 PA; MO; QL (90 per 30 clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg desipramine 1 PA; MO desvenlafaxine succinate dextroamphetamineamphetamine 22 1 ; QL (30 per 30 diazepam intensol 1 PA; MO; QL (240 per 30 diazepam oral solution 5 mg/5 ml (1 mg/ml) 1 PA; MO; QL (1200 per 30 diazepam oral tablet 1 PA; MO; QL (120 per 30 doxepin oral 1 PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg ; QL (60 per 30 ; QL (90 per 30 EMSAM ergoloid

31 escitalopram oxalate oral solution escitalopram oxalate oral tablet ; QL (30 per 30 eszopiclone 1 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) 3 MO; QL (60 per 30 ; QL (60 per 30 3 MO; QL (8 per 28 3 ; QL (28 per 28 ; QL (30 per 30 ; QL (30 per 30 ; QL (60 per 30 ; QL (4 per 28 fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg, 60 mg fluphenazine decanoate ; QL (30 per 30 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg ; QL (60 per 30 ; QL (90 per 30 ; QL (30 per 30 ; QL (60 per 30 FORFIVO XL 3 MO; QL (30 per 30 GEODON INTRAMUSCULA R 3 MO guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral 23 1

32 HETLIOZ (30 per 30 imipramine hcl 1 PA; MO imipramine pamoate 1 PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML 3 MO INVEGA TRINZA LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ; QL (30 per 30 ; QL (60 per 30 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam oral concentrate lorazepam oral tablet 0.5 mg, 1 mg lorazepam oral tablet 2 mg 1 PA; MO; QL (150 per 30 1 PA; MO; QL (90 per 30 1 PA; MO; QL (150 per 30 loxapine succinate maprotiline MARPLAN metadate er methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet,chewable mirtazapine modafinil 1 PA; MO nefazodone nortriptyline 1 PA; MO NUPLAZID ORAL TABLET 17 MG olanzapine intramuscular 4 PA; MO olanzapine oral ; QL (30 per 30 olanzapinefluoxetine paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg ; QL (30 per 30 24

33 paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg, 20 mg, 40 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet extended release 24 hr paroxetine mesylate(menop.sym ) PAXIL ORAL SUSPENSION ; QL (60 per 30 ; QL (30 per 30 ; QL (30 per 30 ; QL (60 per 30 ; QL (60 per 30 ; QL (30 per 30 3 MO perphenazine phenelzine pimozide procentra protriptyline quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg quetiapine oral tablet 300 mg, 400 mg quetiapine oral tablet extended release 24 hr 150 mg, 200 mg ; QL (90 per 30 ; QL (60 per 30 ; QL (30 per 30 quetiapine oral tablet extended release 24 hr 300 mg, 400 mg, 50 mg ; QL (60 per 30 REXULTI ; QL (30 per 30 RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (60 per 30 ; QL (120 per 30 ; QL (60 per 30 ; QL (120 per 30 ROZEREM ; QL (30 per 30 SAPHRIS (BLACK CHERRY) ; QL (60 per 30 25

34 sertraline oral concentrate sertraline oral tablet 100 mg, 50 mg sertraline oral tablet 25 mg ; QL (60 per 30 ; QL (30 per 30 thioridazine thiothixene tranylcypromine trazodone trifluoperazine trimipramine 1 PA; MO TRINTELLIX ; QL (30 per 30 venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet VERSACLOZ 4 VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE ; QL (30 per 30 ; QL (90 per 30 ; QL (90 per 30 ; QL (30 per 30 ; QL (30 per 180 ; QL (30 per 30 VRAYLAR ORAL CAPSULE,DOSE PACK 3 MO; QL (7 per 30 XYREM 4 PA; MO; LA zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG 1 ST; MO; QL (60 per 30 1 ST; MO; QL (30 per 30 3 MO ziprasidone hcl ; QL (60 per 30 zolpidem oral tablet 1 ST; MO; QL (30 per 30 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 210 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral dofetilide flecainide mexiletine 26

35 pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone quinidine gluconate oral quinidine sulfate oral tablet sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 120 mg sotalol oral tablet 160 mg, 240 mg, 80 mg 1 SOTYLIZE ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amlodipine atenolol benazepril betaxolol oral BIDIL bisoprolol fumarate bumetanide BYSTOLIC BYVALSON candesartan captopril amiloridehydrochlorothiazide amlodipinebenazepril amlodipineolmesartan amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide cartia xt carvedilol carvedilol phosphate chlorothiazide chlorthalidone oral tablet 25 mg, 50 mg clonidine ; QL (4 per 28 clonidine hcl oral tablet DEMSER 4 PA; MO 27